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End-Stage Renal Failure (=Terminal Renal Failure)

Definition
Kidney Function is so poor
Patient requires Lifelong Dialysis or Renal Transplantation for survival
Due to underlying Chronic Renal Disease, receive inadequate therapy

Renal Replacement Therapy

Haemodialysis CAPD/ IPD Renal Transplantation
(Continuous Ambulatory Peritoneal Dialysis)
Provide blood a ccess to Haemodialysis Require permanent catheter insertion “Cure” for Chronic Renal Failure
Arteriovenous Fistula (through which dialysis fluid infused & drained out)
Temporary Venous access/ shunt
Diffusion Using Peritoneal Membrane as Dialysis Membrane Forms of Transplant
Solutes at ↑ concentration in blood pass to Allows Mobility while dialysis is being performed Cadaveric Live Donor
↓ concentration in dialysis fluid across membrane Brain Death 1st Degree Blood Relative
Convection (Blood group
As Solutes move, surrounding Solvents are dragged compatibility)
Ultrafiltration (created by machine) Died from 2nd Degree Relative
Excess water moves into dialysis fluid Accident/ (Aunts, Uncles, Nephew)
Blood from patient passed through Extracorporeal circuit Suicide
Blood is expose d to dialysis fluid in Artificial Kidney Died Donors Unrelated Live Donor
Electrolytes, Water exchanges take place without (Developing countries)
ventilator but
functional CVS
Living donor
Nephrectomy does not
cause Renal Failure
Procedures
Transplant Kidneys are placed in Iliac Fossa
Assessment of Graft Function depends on
• Urine Output
• Electrolytes
Require Immun osuppressive Drugs
(Prednisolone, Azathioprine, Cyclosporin A,
IVIG)
Complications Complications Complications
Hypotension / Hypertension Infection Infections
Anaemia Catheter displacement / Obstruction Acute Rejection (usually within 3 months)
Renal Osteodystrophy Loss of Ultrafiltration 2° Malignancy
Dialysis Athropathy Hyperlipidaemia worsen Avascular Necrosis of Femoral Heads
Hyperlipidaemia Worsen Diabetic control ↑ Incidence of CAD
Cystic Renal Disease Recurrent of Original Disease
Aluminium Toxicity
Prognosis
↓ Life expectan cy (due to CVS disease,
Malignancy)
Graft Survival
• 80-85% - 1st year
• 50-60% - 5th year
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Ethics in Dialysis & Renal Transplantation

Dialysis Renal Transplantation

Availability
Shortage of Facilities (expansion requires Money)
(done at other expense of other medi cal services)
Initiating Dialysis
Explain Nature of Illness & Prognosis if Treatment not given
Treatment available must be described
Waiting for Government Facilities (clear guideline for selection criteria)
• 1st come 1st served basis
• Not having debilitating illness other than Kidney failure
• Breadwinner of family
Live Donor selection
Prospective Donor interviewed without Family Members/ Recipient present
Ensure Donor is a Volunteer (no Financial inducement, Coercion)
(Understand Nature of Act & Risk)
Donor Informed – Operation is not free from risk
Risk of Death of Donor (1:1600 Donor Operation)
Donor can change his mind
(Right up to the moment of commen cement of s urgery)
Unrelated Living Donor
Spouse considered (i f no related donor)
Ensure true Volunteer
In China – Convicts become Don or
In India – Kidney bought from Poor
(without appropriate medical prep & protection for Donor & Recipient)
Cadaveric Transplantation
Religions, Races – Consider view
Japan – Brain Death is not accepted as Death
Jews – Accept Brain Death as Death (obligated to donate)
Islam – Transgressing a Death Body is not allowed (validity need conformation)